Chronic pancreatitis: indications to surgery and remote results assessment criteria

Abstract

Present indications to surgery include intractable pain syndrome, severe dilation of the Wirsung’s duct, strictures and stones in the Wirsung’s duct, pancreatic pseudocysts, duodenal stenosis and obstructive jaundice because of “inflammatory mass” in the pancreatic head. But these absolute indications mean that in the most cases pancreatic exocrine and endocrine functions are already decompensated. Therefore it is important to produce new indications to surgical treatment of the CP in early stages. Also it is necessary to make such remote results assessment criteria that will allow to range among parenchymapreserving and resectional technics according to anatomical and functional parameters.

Goal: to adjust indications to surgical treatment of the CP according to leading pathogenetic factors and develop criteria to assess remote results.

Patients and methods: 122 CP patients have undergone surgery. There were 103 (84,4%) men and – 19 (15,6%) women, mean age - 45. Alcohol etiology of the CP was in 79 (64,8%) patients, postpancreonecrotic – in 29 (23,8%), biliary – in 6 (4,9%), idiopathic – in 8 (6,6%). Wirsung’s duct diameter of 4 – 8 mm – was in 65 (53,3%) patients, 8 – 12 and more – in 57 (46,7%). By Shalimov classification there were “pseudotumorous” – in 39 (31,9%), “calculouse” – in 40 (32,8%), fibrose-cystic – in 17 (13,9%), fibrose-degenerative with adjacent organs involvement and hampering of their function – in 26 (21,4%) patients. All patients had pain syndrome and 79 (64,8%) – exocrine and endocrine insufficiency. All patients underwent abdominal CT-scan, fecal elastase test, C-peptide, endogenic insulin, glucose, immunehystochemical investigation of biopsy samples taken from body corpus and tale simultaneously etc.

Results: We have found that gastroenterologists poorly recognize “surgical” type of CP and restrain patients from being directed to surgical pancreatologists for surgical therapy. We suggest that each of the subgroups of TIGAR-O classification must be divided into two parts according to presence of dilation of the Wirsung’s duct: “surgical” type (with dilation of the Wirsung’s duct ≥ 4 mm) and “therapeutic” type (without dilation of the Wirsung’s duct). “Surgical” type of CP is a direct indication to surgery. This approach can save functional reserve of the pancreas.

We developed new criteria to assess late results of pancreatic surgery:

good result: absence of pain and deterioration of pancreatic exocrine and endocrine function, absence of CP complications, that had led to the surgery;

moderate result: pain is present but not intractable, pancreatic exocrine and endocrine function diminished but not severely or present CP complications but no need to perform intervention;

bad result: intractable pain, severe deterioration of pancreatic exocrine and endocrine function, presence of CP complications, that need surgery.

Among our patients who had undergone total longitudinal pancreatowirsungoduodenojejunostomy there were 92,6% of good results, 7,4% - moderate, 0% - bad results. Meanwhile after resection techniques good results were in 53,1%, moderate – in 32,7%, bad – in 14,3% of the patients.

Conclusions:

1. long conservative therapy leads to the deterioration of pancreatic function,
2. necessary cooperation among internist and surgeons is absent,
3. added TIGAR-O classification leads to better understanding of indications to surgery in CP,
4. new criteria must contain functional parameters.

Key words: chronic pancreatitis, ductal hypertension, surgery indications, life quality assessment